Lamellar corneal surgery has undergone a steady evolution. Advancements in the technology, such as automated keratomes and non-freeze, no-suture techniques have markedly improved safety and effectiveness. When Dr. Luis Ruiz introduced the automated keratome and the in situ non-freeze, no-suture technique to the lamellar bed, other physicians embraced this and have since introduced this technique to thousands of surgeons worldwide. Although a significant advancement, even Dr. Luis Ruiz realized the relative imprecision of making a refractive pass with the keratome. He quickly learned to utilize the excimer laser to precisely reshape the cornea underneath the lamellar corneal flap. The precision achieved has been unparalleled, especially for the moderate to higher myopes.
Worldwide there have been many other surgeons that deserve credit for pursuing the combination of excimer laser with lamellar surgery. As surgeons began doing lamellar corneal surgery, they became concerned about the potential for inducing irregular astigmatism as well as introducing debris such as epithelial inclusions in the stromal interface. Fortunately, with the introduction of the automated keratome and non-freeze, non-suture techniques, irregular astigmatism rates are reduced but still pose a great problem. Debris in the interface also continues to be a chronic problem. Many surgeons have resorted to never wearing gloves during lamellar surgery just for that reason. Although infections in lamellar surgery are quite low, infection percentages, however low, need to be reduced and preferably eliminated. At present, it is unclear whether or not wearing gloves during lamellar surgery is the standard of care. Thus, we need a way to perform lamellar surgery with gloves safely so as not to introduce debris into the interface.
Recently a very famous clinical researcher in excimer laser technology expressed that his job is now to make surface ablation PRK (photorefractive keratectomy) as good or better than LASIK (laser assisted in situ keratomileusis). Preserving all the layers of the cornea provides quicker visual recovery and the predictability is less dependent on the ablation characteristics of the laser. Thus, LASIK in its infancy already has a head start over any surface ablation technique. Secondly, while PRK retreatment is not predictable, LASIK enhancement is possible. The tremendous amounts of research and development required to create the perfect surface ablation could be better spent in perfecting LASIK for all ranges of refractive errors.
There is a growing need to introduce lamellar surgery skills to surgeons new to this arena. Surgeons who have been performing ALK (automated lamellar keratoplasty) will be prepared to make an easy transition to LASIK. Many of the surgeons making the transition from PRK to LASIK appear totally consumed in what type of ablation to use in the bed, when in reality their primary concerns should be a safe keratectomy and repositioning the corneal cap/flap so that there is the least likely chance for debris in the interface causing irregular astigmatism. If that can be consistently reproduced, then enhancement is possible and predictability of the ablation for each surgeon will increase with experience.